From the editor: on being unseen

An almost textbook definition of mainstreaming is to integrate something into another so seamlessly, that it becomes unseen as a separate entity. It does not stand out as an add-on, but is interwoven into the very fabric of being. It has been a long held hope and goal of many who have worked with Intervention that one day the proper attention to mental health and psychosocial support will be interwoven into the very fabric of all humanitarian aid work. With this issue, we hope to have taken one step closer to that goal, by proudly presenting a Special section: ‘Mainstreaming psychosocial approaches into other sectors’.

For this section, we have collaborated closely with two special guest editors: Rebecca Horn (an independent psychosocial specialist, member of the Church of Sweden psychosocial roster and a member of Intervention's Editorial board) and Djoen Besselink (a social psychologist and consultant specialising in psychosocial humanitarian interventions and management). Additionally we are very grateful to UNICEF and the Church of Sweden for having made these extra pages financially possible.

This is far from the first time that Intervention has focused on how mental health and psychosocial support (MHPSS) should be integrated into other fields. Indeed it has been a subject that has been interwoven into the journal for the past decade. In 2006, Williamson and Robinson pleaded for an integrated model in these pages. In the Introduction to the Special section our Guest editors elaborate on this and discuss the differences between an intervention and an approach. The key element of mainstreaming MHPSS into other sectors is that MHPSS becomes an approach, meaning that all of those involved in aid work think and look through a MHPSS lens, even if working in completely different sectors. This is not something that is easy to show, or to highlight, as if achieved it remains often unseen. For that reason, it is also essential that policy makers and funders are aware how important proper attention to include MHPSS in all sections of humanitarian aid is for beneficiaries. That means that advocacy also needs to be included in the MHPSS toolbox. Last year, the Dutch government decided that every time they support organisations working in emergency settings, a percentage would be spent on MHPSS. This was the result of advocacy.

Four important articles and two field reports address these issues of mainstreaming into other sectors in very different fields, and on very different levels, as well provide possibilities and challenges for the future. I will not dwell on these more here, as they are eloquently discussed in the Introduction to the Special section that may be found after the Current affairs section.

For the second time, our new section Current affairs, addresses current crises and questions that arise from theses crises from the perspective of MHPSS. We have two contributions in this section that may be said to show the negative aspects of remaining ‘unseen’: one is on the long-lasting impact of bomb blasts and other violent attacks for political or religious reasons, the other on those who have been working in areas of violence that have been going on for so long, as to be almost forgotten.

Although not often in the news, the concealed and often tragic results of political or religious violence has increased dramatically over the past few years, as have the number of those traumatised by it. It is perhaps fitting that we go to press as the 15 year anniversary of 9/11 is commemorated and highlights the need to pay more attention to the long-term impact of this sort of violence.

Dilwar Hussain and Prakasah Sarma describe the social-economic and psychological effects of terrorist bomb blasts on the lives of survivors. They interviewed survivors of a terrible bomb attack in India several years ago and show that these people still struggle with psychological problems, but also that the experiences has had dramatic influence on their social and economic position, affecting the children and families of these survivors as well. Sadly, there is little support for those who have been impacted, or their families.

In his personal reflection, Maximilien Zimmermann addresses his experience in supporting psychosocial workers in Palestine who, in turn, support family members who have lost their loved ones and were victims of violent attacks by Israeli settlers. He pleads for more tools and interventions to support these psychosocial workers who are working in an area of long standing and ongoing violence.

Next to these two sections, we have also our ‘normal’ contributions in what is a hugely packed issue.

Constanze Quosh addresses case management. She describes the approach, implementation and evaluation of a pilot mental health and psychosocial support case management programme in Syria. She discusses different forms of case management approaches based on a multi-layered, stepped care model. This approach presents a functional case management system and shows positive mental health outcome results.

The following three articles all addresses the difficulties of refugees and displaced people, but in very different ways: through a perceived needs survey, a qualitative research among parents and a personal account of internally displaced women. All three are, in their own way, important, not only to be seen and understood, but also continue to highlight the theme of the importance of mainstreaming MHPSS into other sectors.

Boris Budosan, Sabah Aziz, Marie Theres Benner and Batouel Abraspresent their ‘Humanitarian Emergency Settings Perceived Needs Scale (HESPER) survey’. The survey shows how diverse the needs and how difficult the life for Syrian refugees in Turkey, and as such, it HESPER may answer the need for a quick assessment instrument within emergency settings. Their use of the instrument in this study showed a variety of perceived needs and daily stressors, as well as the hardship impacting the urban, Syrian refugee community. Again, we see that wellbeing is connected to such myriad aspects that mainstreaming MHPSS has become a necessity.

In their article, ‘Youth resilience makes a difference in mitigating stress: teacher mediated school intervention in Bethlehem’, Mohammed Shaheen and Shani Opperheim present a study of the implementation of the ‘Enhancing resiliency amongst students experiencing stress’ intervention’. Their hypothesis was that posttraumatic stress levels can be reduced when youth have higher levels of ego resilience, and that this could be though a teacher mediated school intervention. The study did not support their hypothesis, but offers much to learn, and they plead for a more holistic approach in areas where people are exposed to continuous violence.

The field report of Elvia Ramírez, Arely del Pilar Gómez Ramírez, Clara Gesteira Santos, Roberto Chaskel, Zelde Espinel and James M. Schultz is a blend of a personal reflection and a field report. In this paper, two Colombian internal displaced women, a mother and her daughter, tell the reader their experiences and the difficulties displaced people face when they, coming from rural areas, have to survive in Bogotá, as ‘ghosts in the big city’. Yet, another of the negative aspects of being ‘unseen’, often these stories have gone unheard in this decades long, brutal violence that has resulted in Colombia having a huge internally displaced population who have survived the hardship of displacement due to the war. While the peace agreement was signed recently (24 August), even though the population voted it down in a referendum, it, therefore, remains to be seen how many of those IDPs will now feel safe enough to come out of the shadows and speak.

The final contribution is a personal reflection of Jack Obali Odolla who describes the difficulties young people face when they are forced to return to Ethiopia, after working abroad. These young people usually went abroad for economic reasons and instead of bringing money home to their families (as was expected) they have experienced exploitation, violence and trafficking. Back in Ethiopia, their problems are not over as many families do not understand the problems these returnees have faced, are disappointed and sometimes reject those returning home.

Finally, I would like to highlight a call for papers. After the Special section in 2013 on peacebuilding and psychosocial work, Interventionhas the opportunity to publish an extra issue on linking mental health and psychosocial support to peacebuilding. The Institute for Justice and Reconciliation (IJR) in South Africa and the Netherlands based War Trauma Foundation would like to jointly try to narrow the gaps between workers in the field of MHPSS and ‘peacebuilders’. With this extra issue, aimed at workers in both groups, we hope to strengthen the nexus, linkage and mutual understanding between these two essential fields.

CURRENT AFFAIRS

Socio-economic and psychological effects of terrorist bomb blasts on the lives of survivors: an exploratory study on affected individuals

Abstract: This study explored the socio-economic and psychological effects of terrorist bomb blasts on the lives of survivors, using a qualitative research method. Results have shown that, although several years may have elapsed since the event, respondents were yet to recover from its effects. Those who survived still carry the scars to constantly remind them of the horrific ordeal. They are tormented by psychological issues which, for them, are often more difficult to deal with compared to the trouble and pain caused by physical injuries sustained. Most of the participants have experienced frequent stress related psychological symptoms, as well as other associated symptoms such as sadness, depression, anxiety, irritability, lack of concentration in daily activities, nightmares and flashbacks of events. Additionally, there has been serious long term socio-economic effects of terrorist bomb blasts on the survivors, such as unemployment, uncertainty over the education of their children and declining health status. Furthermore, as well as dwindling social-economic status, inadequate government support and lack of follow-up in terms of rehabilitation are among the most pressing problems faced by this group of survivors, which needs to be urgently and properly addressed.

When psychological first aid is not enough: personal reflections on psychosocial interventions in Duma, a village in north West Bank

Abstract: This personal reflection describes the experience of a Swiss/Belgian psychologist who has been working as a mental health programme coordinator in Palestine for Médecins du Monde France for 2.5 years. His reflection (which does not necessarily reflect the view of Médecins du Monde France) touches on the importance of rethinking psychosocial interventions for individuals and communities facing continuous critical events. The author also reflects on his background, his motivation and challenges, as well the impact of the current situation on Médecins du Monde, in terms of both international and national staff.

SPECIAL SECTION

Introduction to Special section: mainstreaming psychosocial approaches and principles into ‘other’ sectors

The integration of livelihood support and mental health and psychosocial wellbeing for populations who have been subject to severe stressors

Abstract: This article aims to promote the integration of mental health and psychosocial support into livelihood programmes, presenting existing research within behavioural economics, humanitarian and economic fields that support the need and effectiveness of such integration. It presents examples of mental health and psychosocial support integration into livelihood programmes put in place by a grass roots organisation in the USA and the largest development institution in the world, the World Bank Group, respectively. While these initiatives took place within organisational, socio-economic and political environments that significantly differ from those where most humanitarian programmes take place, a series of best practices, processes and approaches that could be considered within humanitarian settings are highlighted in the conclusions.

Abstract: The field of mental health and psychosocial support (MHPSS) in emergencies has been slow to engage with the growing global policy consensus around disaster risk reduction (DRR) as embodied by the Hyogo Framework for Action and its successor, the Sendai Framework for Disaster Risk Reduction. However, there are encouraging recent efforts to harness the synergies that exist between the fields of DRR and MHPSS. As these linkages between the fields of MHPSS and DRR are still in an early stage of development, our attempt to outline a preliminary basis for how the objectives of the two fields may be combined in practice, and conceptually, might help move this process forward. It is in the interest of the MHPSS field to invest further in ways and means of integrating with the fast growing, dynamic and increasingly influential field of DRR. In turn, the field of MHPSS has much to offer by way of perspectives and approaches that can amplify the impact of DRR activities on the quality of life of people who are at risk of experiencing hazards or disasters. We believe this paper will demonstrate this and encourage others in the MHPSS field to seek greater dialogue and integration between the two fields.

Mainstreaming mental health and psychosocial support in camp coordination and camp management. The experience of the International Organization for Migration in the north east of Nigeria and South Sudan

Abstract: This article examines the efforts of the International Organization for Migration to mainstream mental health and psychosocial considerations into camp coordination and camp management, through capacity building and provision of direct psychosocial support. It focusses on the activities carried out by the International Organization for Migration in South Sudan, in the Protection of Civilians Areas, and in the north east of Nigeria, with the aim to identify relevant challenges and best practices.

Not doing more, but doing differently: integrating a community based psychosocial approach into other sectors

Abstract: A multi-layered approach to mental health and psychosocial support in emergencies includes the integration of psychosocial approaches into sectors with primary aims other than the enhancement of mental health and psychosocial support. This paper shares the experiences of Church of Sweden's psychosocial team in supporting its partner organisations (within the ACT Alliance) to integrate a community based psychosocial approach into programmes in sectors including: education, child protection, livelihoods, water and sanitation, and food security. Case studies are used to describe how mental health and psychosocial support core principles can assist organisations to integrate psychosocial approaches into a variety of programmes, and to demonstrate that this is more about working in a different way than about taking on additional tasks. The challenges associated with supporting organisations to integrate psychosocial approaches into their programmes are also outlined, and the need for research to evaluate the effectiveness of this type of approach is acknowledged.

ARTICLES

Abstract: This article describes the approach, implementation and evaluation of a pilot mental health and psychosocial support case management programme that was developed by the United Nations High Commissioner for Refugees in Syria. The aim was to provide a description of the programme approach, its implementation and outputs. The programme integrates different forms of case management approaches based on a multi-layered, stepped care model. Earlier results of mixed method monitoring and evaluation revealed improvement in wellbeing among programme participants. The step-wise approach indicates, in addition to the positive mental health outcome results, a functional case management system.

Abstract: The largest number of Syrian refugees in the world are currently hosted in Turkey, with the great majority of them residing in urban settings. This paper presents the findings of The Humanitarian Emergency Settings Perceived Needs (HESPER) Scale survey conducted with the population of urban Syrian refugees in the town of Kilis in south-central Turkey in 2013. The high level and variety of perceived needs and daily stressors shows the magnitude and hardship in the urban Syrian refugee community in Kilis. Issues such as: income/livelihood; clothes, shoes, bedding or blankets; the way aid is provided; being displaced from home; a place to live in; distress; education for your children; and physical health were considered as priorities by most of the HESPER survey participants. A subsequent in-depth participatory assessment in the town of Kilis in February 2014 was useful for better understanding of the expressed needs of the urban Syrian refugee population, designing mental health and psychosocial support interventions and providing recommendations to humanitarian actors.

Abstract: This study examined the implementation of the Enhancing Resiliency Amongst Students Experiencing Stress intervention, which is a teacher mediated, evidence based school intervention, targeting youth who have been exposed to ongoing conflict. Our hypothesis was that posttraumatic symptom levels can be reduced when youth have higher levels of ego resilience and that this can be achieved through a teacher mediated, school intervention. We found that ego resilience is negatively related to posttraumatic symptom levels, while anxiety levels and impairment in functioning are positively related. However, in contradiction to our hypotheses, we also found that the school intervention was not sufficient to contribute significantly between the pre and post measures and resulted in higher levels of posttraumatic symptom levels, anxiety levels and impairment in functioning. These findings are explained within the context of the harsh environment in which the students and their families live. Additionally, our findings indicate that implementing a school intervention within the context of continuous exposure to traumatic events may require a more holistic approach.

FIELD REPORTS

Abstract: In the Central African Republic, a political crisis started in 2013 that greatly affected the population. They were exposed to traumatogenic factors causing the emergence of symptoms of posttraumatic stress disorder in large segments of the population. The situation of high food insecurity, combined with high levels of psychological distress, have significantly limited the population's coping strategies. Within this context, the nongovernmental organisation, Action Contre la Faim, implemented a programme aimed at addressing both immediate and underlying causes of malnutrition, integrating psychosocial and food security approaches. In order to improve the access to food, 900 pregnant and lactating women received monthly food coupons that were exchangeable in the local market. Of these, 199 women who had been identified as the most psychologically vulnerable benefited from specific support: individual counselling or therapeutic groups. Through this multi-sectoral approach, the women's average individual dietary diversity score increased and households improved their food consumption score. Further, these women improved their psychological wellbeing and were able to regain some degree of hope and to develop coping skills. They regained confidence and felt stronger and more prepared to face the future, showing that this multi-sectoral approach strengthened family resilience.

In spite of the clarity of mental health and psychosocial core principles: the existence of a participation implementation gap

Abstract: According to humanitarian minimal standards, humanitarian programmes should maximise participation of affected populations within their response. Participation has been a key point in proposals, evaluators are aware of it and every aid worker has heard of it. In theory, it is a perfectly implemented, well understood and a well respected construct. In the field of mental health and psychosocial support, participation is core principle number two. Based on personal observations, this paper will delve deeper into the concept of participation within mental health and psychosocial support and the importance of its implementation. Further, and perhaps more importantly, it will reflect on the fact that even though this concept is so imbedded into concepts of humanitarian aid, there is a huge implementation gap. As a result, this paper also calls for action to fill this implementation gap and improve humanitarian aid through the principle of participation.

Ghosts in the big city: surviving and adapting to internal displacement in Colombia, South America

Abstract: The signing of the truce on 23 June 2016 and the finalisation of peace negotiations on 24 August 2016 marked the end of more than 50 years of continuous armed conflict in Colombia, South America and the transition to ‘post conflict’ status. According to annual reports from the Internal Displacement Monitoring Centre based in Geneva, Switzerland, Colombia has ranked first or second in numbers of internally displaced persons every year for the past 12 years, making forced migration a defining characteristic of the country. This is based on the personal reflections of a mother and daughter (ER and AdPGR) who were displaced from rural Colombia and resettled in the nation's urban capital of Bogotá. They survived the rigors and hardships of displacement and became capable counsellors on a global mental health project, bringing evidence based interventions to a highly traumatised population of internally displaced women in Bogotá. Their account speaks to the lived experiences of more than six million Colombian internally displaced ‘victims of the armed conflict’. Particularly notable is the description of myriad trauma exposures prior to the moment of displacement. This field report demonstrates how personal accounts are a useful tool for educating clinicians working with these populations.

REFLECTIONS, COMMENTS, LETTERS

The other side of ‘economic migration’: psychosocial issues affecting young people returning to Ethiopia

Abstract: Families in Ethiopia, with few opportunities to generate income, sometimes send a young family member to work abroad. In many cases, the family sells property to raise the necessary funds, and therefore, expect that much of the income earned will be sent home. However, young migrants are often vulnerable to exploitation and abuse and may want to return home, or need to return after violence breaks out in their country of migration. Yet, returning home raises a number of challenges, not least those involved in returning empty-handed. In this personal reflection, I discuss working with the International Organization for Migration assisting young returnees to Ethiopia, explore the psychosocial issues affecting those who migrate and return, and put forward suggestions as to how their psychosocial wellbeing can be strengthened.